The value of multivessel percutaneous coronary intervention (MV-PCI) in patients with cardiogenic shock (CS) and multivessel disease (MVD) is still unclear because randomized controlled trials are missing. Therefore, we sought to evaluate the impact of MV-PCI on in-hospital outcomes of patients with MVD presenting with CS: 336 patients with acute myocardial infarction complicated by CS and ≥70% stenoses in ≥2 major epicardial vessels were included in this analysis of the Euro Heart Survey PCI registry. Patients undergoing MV-PCI (n = 82, 24%) were compared to those with single-vessel PCI (n = 254, 76%). The rate of 3-vessel disease (60% vs 57%, p = 0.63) was similar in the 2 cohorts. Presentation with resuscitation (48 vs 46%, p = 0.76) and ST-segment elevation myocardial infarction (83 vs 87%, p = 0.31) was frequent in patients with MV-PCI and single-vessel PCI. Patients with ventilation were more likely to receive MV-PCI (30% vs 19%, p = 0.05). There was a tendency toward a higher hospital mortality in patients with MV-PCI (48.8% vs 37.4%, p = 0.07). After adjustment for confounding variables, no significant difference for in-hospital mortality (odd ratio [OR] 1.28, 95% confidence interval [CI] 0.72 to 2.28) could be observed between the 2 groups. Age (OR 1.41, 95% CI 1.13 to 1.77), 3-vessel disease (OR 1.78, 95% CI 1.04 to 3.03), ventilation (OR 3.01, 95% CI 1.59 to 5.68), and previous resuscitation (OR 2.55, 95% CI 1.48 to 4.39) were independent predictors of hospital death. In conclusion, MV-PCI is currently used in only 1/4 of patients with CS and MVD. An additional nonculprit PCI was not associated with a survival benefit in these high risk patients.
Despite the use of early revascularization therapies and improved adjunctive medical treatment the prognosis of patients with cardiogenic shock (CS) complicating acute myocardial infarction remains poor. In patients with CS multivessel disease (MVD) is common and associated with an increased hospital mortality. The European Society of Cardiology guidelines for percutaneous coronary intervention (PCI) recommend that “in the setting of cardiogenic shock there is a consensus for attempting multi-vessel percutaneous coronary intervention (MV-PCI) in selected patients with multiple critical lesions.” However, data from randomized trials are missing and data from case series are controversial. We therefore analyzed data from the Euro Heart Survey PCI Registry to determine the impact of MV-PCI on in-hospital outcome of patients with MVD presenting with CS.
Methods
The Euro Heart Survey PCI Registry is a prospective multicenter observational study on current practice of unselected patients undergoing elective or emergency PCI. Consecutive patients with acute coronary syndrome or stable coronary artery disease were recruited from May 2005 through April 2008. Participating hospitals were located throughout Europe (176 centers in 33 European Society of Cardiology countries) and included university hospitals, community hospitals, specialist cardiology centers, and private hospitals providing PCI. The mean annual PCI volume of participating facilities was approximately 1,000. During specified periods all patients treated with PCI were prospectively registered and followed during their clinical course to document patient characteristics, adjunctive medical treatment, procedural details, and in-hospital outcomes. In total 47,407 patients were enrolled in the Euro Heart Survey PCI Registry. Of these 678 patients with acute coronary syndrome were in cardiogenic shock at the start of PCI. Patients with ≥70% stenoses of ≥2 major epicardial vessels (n = 336) were analyzed and divided into 2 groups: group A with MV-PCI and group B with single-vessel (SV) PCI. Patients with only 1 ≥70% stenosed vessel (n = 263), previous coronary artery bypass grafting (n = 14), and left main coronary artery disease (n = 88) were excluded. On admission data on patient characteristics were recorded including age, gender, cardiovascular risk factors, concomitant diseases, previous myocardial infarction, previous stroke, previous cardiovascular interventions, and long-term medical treatment and data on symptoms and prehospital delay. Data on electrocardiographic findings, biochemical markers, procedural details, and adjunctive therapy were documented. At discharge major cardiovascular, cerebrovascular adverse events, puncture site complications, and recommended medical treatment were recorded. Every participating center was committed to include every consecutive patient undergoing PCI during selected periods. All patients gave written informed consent for processing their anonymous data. Electronic case-report forms were used for data entry and transferred by the Web to a central database located in the European Heart House, where they were edited for missing data, inconsistencies, and outliers. Additional editing of the data and statistical analyses for this publication were performed at the Institut für Herzinfarktforschung Ludwigshafen an der Universität Heidelberg, Germany. The study was approved by the ethics committees responsible for the participating centers as required by local rules. Cardiogenic shock was defined according to the following clinical criteria: systolic blood pressure ≤90 mm Hg for ≥30 minutes or inotropes needed to maintain blood pressure >90 mm Hg and evidence of end-organ hypoperfusion and increased filling pressures. Postprocedural reinfarction was diagnosed if patients had signs of recurrent ischemia and an additional relevant increase of cardiac biomarkers. Bleeding complications were classified as major when the patient had an intracranial bleed or an overt clinical bleeding with a decrease in hemoglobin of >5 g/dl. Chronic renal failure was diagnosed by any of the following: serum creatinine >2 mg/dl or 200 μmol/L previously, on dialysis, or history of renal transplantation. Categorical data are presented as absolute numbers and percentages, metrical data as mean ± SD or median. Frequencies of categorical variables in the 2 populations were compared by Pearson chi-square test, and distributions of metrical variables by Mann–Whitney–Wilcoxon test. Descriptive statistics were calculated from the available cases. We evaluated the effect of MV-PCI on hospital mortality in a multiple logistic regression model in which adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated. In addition to MV-PCI the following risk markers that had been specified by clinical considerations were included in the model: age, 3-vessel disease, previous resuscitation, ventilation, intra-aortic balloon pump, and inotropic agents. In unadjusted comparisons all these variables were significantly (p <0.02) associated with hospital mortality. The discrimination of the model was assessed with the c-statistic (c = 0.737). All p values ≤0.05 were considered statistically significant. All p values are results of 2-tailed tests. Analysis was performed with SAS 9.1 (SAS Institute, Cary, North Carolina) on a personal computer.
Results
For the present analysis 336 patients were stratified into 2 categories: 82 patients (24%) undergoing MV-PCI and 254 patients (76%) undergoing SV-PCI. Baseline characteristics of the patients are listed in Table 1 . Percentage of 3-vessel disease was similar in the 2 groups. In patients with SV-PCI (sub-)total occlusions and Thrombolysis In Myocardial Infarction grade 0 flow were more often observed before PCI ( Table 2 ). Stenoses ≥70% of the left anterior descending, left circumflex, and right coronary arteries were present in 159 patients (47%) but in only 4% of patients was an intervention performed in all 3 vessels ( Figure 1 ) . The combination of right and left anterior descending coronary artery stenosis ≥70% was more frequent (24%) than left anterior descending coronary artery with left circumflex coronary artery (19%) and right coronary artery with left circumflex coronary artery (10%). However, the left anterior descending and left circumflex coronary arteries were more often treated together (11%) than the right and left anterior descending coronary arteries (7%) or the right and left circumflex coronary arteries (5%). Despite multiple stenosed vessels, SV interventions in the left anterior descending (35%), right (28%), or left circumflex (13%) coronary artery were favored most. In total, the left anterior descending coronary artery was stenosed ≥70% in 302 patients and treated in 61% of these, the right coronary artery was stenosed in 274 patients and treated in 51%, and the left circumflex coronary artery was stenosed in 255 patients and treated in 39%. There were no differences in procedural success between the 2 groups. Stent thrombosis occurred more frequently in patients with MV-PCI ( Table 2 ). Treated left anterior descending coronary artery lesions were more often severely stenosed (≥90%, 85% vs 57%, p <0.001) and located proximally (55% vs 22%, p <0.0001) compared to untreated left anterior descending coronary artery stenoses in patients with SV-PCI. There were no relevant differences in the use of antithrombotic treatment and inotropic agents between the 2 groups ( Table 3 ). Hospital mortality tended to be higher in patients with MV-PCI ( Figure 2 ) . In multivariate analysis no significant difference in the risk of hospital death (OR 1.28, 95% CI 0.72 to 2.28) could be observed between the 2 groups ( Figure 3 ) . The incidence of nonfatal postprocedural myocardial infarction, stroke, major bleeding, renal failure requiring dialysis, and emergency coronary artery bypass grafting did not significantly differ between patients with MV-PCI and SV-PCI ( Figure 2 ). Overall rate of planned (elective) coronary artery bypass grafting was low in the 2 groups (3% vs 5%, p = 0.42). Baseline clinical variables did not significantly differ between patients with MV-PCI and Thrombolysis In Myocardial Infarction grade 0 to 1 (n = 35) and those with Thrombolysis In Myocardial Infarction grade 2 to 3 flow (n = 45) in the remaining treated vessel. Procedural success of the remaining treated vessel was significantly lower in those with Thrombolysis In Myocardial Infarction grade 0 to 1 flow before PCI (Thrombolysis In Myocardial Infarction grade 3 flow after PCI, 46% vs 89%, p <0.0001; <50% stenosis after PCI, 57% vs 93%, p <0.0001). Hospital mortality was similar in the 2 groups (51% vs 47%, p = 0.67). In multiple regression analysis age (per 10-year increase, OR 1.41, 95% CI 1.13 to 1.77), 3-vessel disease (OR 1.78, 95% CI 1.04 to 3.03), ventilation (OR 3.01, 95% CI 1.59 to 5.68), and previous resuscitation (OR 2.55, 95% CI 1.48 to 4.39) were associated with an increased risk for hospital death. Intra-aortic balloon pump (OR 1.70, 95% CI 0.94 to 3.08) and inotropes (OR 1.36, 95% CI 0.78 to 2.37) tended to be linked with a higher hospital mortality ( Figure 3 ).
| Variable | MV-PCI (n = 82) | SV-PCI (n = 254) | p Value |
|---|---|---|---|
| Age (mean) | 67.2 ± 12.2 | 65.4 ± 12.2 | 0.22 ⁎ |
| Women | 29% | 32% | 0.61 |
| Body mass index (kg/m 2 ) | 27.1 ± 4.3 | 27.6 ± 4.4 | 0.57 ⁎ |
| Previous myocardial infarction | 32% | 36% | 0.45 |
| Previous percutaneous coronary intervention | 9% | 13% | 0.38 |
| Heart failure | 9% | 11% | 0.69 |
| Valvular disease † | 7% | 3% | 0.17 |
| Previous stroke | 8% | 8% | 0.98 |
| Peripheral artery disease | 7% | 9% | 0.5 |
| Chronic renal failure | 9% | 6% | 0.35 |
| Hypertension ‡ | 60% | 67% | 0.27 |
| Diabetes mellitus | 40% | 35% | 0.51 |
| Hypercholesterolemia § | 47% | 55% | 0.3 |
| Current/former smoker | 55% | 54% | 0.94 |
| Presentation | |||
| ST-segment elevation myocardial infarction | 83% | 87% | 0.31 |
| Anterior ST-segment elevation myocardial infarction | 47% | 48% | 0.89 |
| Posterior ST-segment elevation myocardial infarction | 53% | 52% | 0.89 |
| Prehospital delay (hours:minutes) | 2:00 | 2:00 | 0.99 ⁎ |
| Door-to balloon time (hours:minutes) | 0:55 | 1:15 | 0.19 ⁎ |
| Non–ST-segment elevation acute coronary syndrome | 17% | 13% | 0.31 |
| Prehospital resuscitation | 48% | 46% | 0.76 |
| Ejection fraction | 0.71 | ||
| >50% | 16% | 12% | |
| 41–50% | 8% | 12% | |
| 31–40% | 33% | 30% | |
| ≤30% | 43% | 46% |
† History of valvular disease diagnosed and/or treated by a physician.
‡ History of hypertension diagnosed and/or treated by a physician.
§ History of hypercholesterolemia diagnosed and/or treated by a physician.
| Variable | MV-PCI | SV-PCI | p Value |
|---|---|---|---|
| (n = 82) | (n = 254) | ||
| Stenosed vessels (≥70%) | |||
| Left anterior descending coronary artery | 93% | 89% | 0.33 |
| Left circumflex coronary artery | 85% | 73% | <0.05 |
| Right coronary artery | 73% | 84% | <0.05 |
| 3-Vessel disease | 51% | 46% | 0.42 |
| Vessels treated | |||
| Left anterior descending coronary artery | 81% | 47% | <0.0001 |
| Left circumflex coronary artery | 71% | 17% | <0.0001 |
| Right coronary artery | 56% | 37% | <0.01 |
| Details of first treated vessel | |||
| Thrombolysis In Myocardial Infarction flow before percutaneous coronary intervention | <0.01 | ||
| Thrombolysis In Myocardial Infarction 0 | 49% | 68% | |
| Thrombolysis In Myocardial Infarction 1 | 8% | 10% | |
| Thrombolysis In Myocardial Infarction 2 | 21% | 10% | |
| Thrombolysis In Myocardial Infarction 3 | 23% | 11% | |
| 99–100% stenosis | 66% | 77% | <0.05 |
| Thrombolysis In Myocardial Infarction 3 flow after percutaneous coronary intervention | 78% | 74% | 0.4 |
| <50% stenosis after percutaneous coronary intervention | 90% | 88% | 0.57 |
| Thrombolysis In Myocardial Infarction 3 + <50% stenosis after percutaneous coronary intervention | 77% | 71% | 0.34 |
| Bare-metal stent | 59% | 61% | 0.66 |
| Drug-eluting stent | 29% | 23% | 0.28 |
| Stenosis of remaining vessels | |||
| Occlusion (100%) | 54% | 46% | 0.22 |
| Stenosis degree of nonocclusions (%) | 90 (65–95) | 80 (70–90) | 0.08 |
| Details of remaining vessels | |||
| Thrombolysis In Myocardial Infarction 0 flow before percutaneous coronary intervention | 38% | — | |
| 99–100% stenosis | 55% | — | |
| Thrombolysis In Myocardial Infarction 3 flow after percutaneous coronary intervention | 70% | — | |
| <50% stenosis after percutaneous coronary intervention | 76% | — | |
| Periprocedural complications | |||
| Acute segment closure | 4% | 2% | 0.28 |
| Coronary perforation | 0.00% | 0.40% | 0.56 |
| No/slow flow | 12% | 12% | 0.9 |
| Stent thrombosis | 9% | 2% | <0.01 |
| Other therapeutic periprocedural measures | |||
| Intra-aortic balloon pump | 33% | 24% | 0.11 |
| Ventilation | 30% | 19% | 0.05 |
| Pacemaker | 19% | 11% | 0.06 |
| Defibrillation | 17% | 10% | 0.09 |
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